RESEARCH ARTICLE Open Access

Representation to the accident and emergencydepartment within 1-year of a fractured neck offemurDavid J Bryson1*, Scott Knapp1, Rory G Middleton1, Murtuza Faizi1, Hardik Bhansali2 and Chika E Uzoigwe1

Abstract

Background: The fractured neck of femur (NOF) is a leading cause of morbidity and mortality. The mortalityattendant upon such fractures is 10% at 1 month and 30% at one year with a cost to the NHS of £1.4 billionannually. This retrospective study sought to examine rates and prevailing trends in representation to A&E in theyear following a NOF fracture in an attempt to identify the leading causes behind the morbidity and mortalityassociated with this fracture.

Methods: 1108 patients who suffered a fractured NOF between 1 January 2002 and 31 December 2007 wereidentified from a University Hospital A&E database. This database was then used to identify those patients whorepresented within 1-year following the initial fracture. The presenting complaint, provisional diagnosis and theoutcome of this presentation were identified at this time.

Results: 234 patients (21%) returned to A&E on 368 occasions in the year following a hip fracture. 77% (284/368) ofthese presentations necessitated admission. Falls, infection and fracture were the leading causes of representation. Fallsaccounted for 20% (57/284) of admissions; 20.7% of patients were admitted because of a fracture, while 56.6% ofadmissions were for medical ailments of which infection was the chief precipitant (28% (45/161)).

Discussion: The causes for representation are varied and multifactorial. The results of this study suggest that someof those events or ailments necessitating readmission may be obviated and potentially reduced by interventionsthat can be instituted during the primary admission and continued following discharge.

Keywords: Fractured neck of femur, morbidity, mortality, falls, fragility fracture

IntroductionThe fractured neck of femur is a leading cause of morbid-ity and mortality. Hip fracture places considerable physicaland physiological strain on the patient and upon theresources of the NHS. In 1990 there were an estimated 1.3million hip fractures worldwide [1]. With a populationincreasingly surviving into later decades of life this figureis set to grow by more than 480% to reach 6.3 million by2050 [2]. Estimates place the incidence of neck of femurfractures at 70,000 - 86,000 per year in the UK [1,3] withan average cost to the NHS of £1.4 billion annually [4].The mortality attendant upon such fractures is 10% at

1-month and 30% at one year [3]. With the UK incidenceof hip fractures anticipated to breach 100,000 cases withinthe next decade [5] the demands placed upon a servicealready operating at, or close to, full capacity are only setto increase.As clinicians and surgical practitioners we are routinely

called upon to discuss the pros and cons, the intendedbenefits and risks of particular surgical procedures withpatients and their families. While the epidemiology andpathology of venous thromboembolism, wound infectionor neurovascular damage are easy to describe andaccount for, the morbidity and mortality associated withhip fracture is not so easy to explain. Despite surgicalfixation nearly one third of patients will suffer declininghealth and die within one year. While the procedure maybe curative and the fracture fixed and stabilised, a

* Correspondence: davidjbryson@hotmail.com1Department of Trauma and Orthopaedics, Leicester Royal Infirmary,Infirmary Road, Leicester LE1 5WW, UKFull list of author information is available at the end of the article

Bryson et al. Journal of Orthopaedic Surgery and Research 2011, 6:63http://www.josr-online.com/content/6/1/63

© 2011 Bryson et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

successful outcome is not guaranteed. When relativesenquire about prognosis and the reason for this 30%mortality an answer is not always readily available. Thereason for this is unclear–what accounts for the morbid-ity and resultant mortality?In an attempt to understand and identify the leading

causes and factors implicated in this morbidity we under-took a retrospective review examining the prevalence andcauses for representation to acute medical services in theyear following a hip fracture.

MethodsWe used an A&E coding database to identify patientswho had presented to a University Hospital emergencydepartment with a fractured neck of femur between 1January 2002 and 31 December 2007. This is a compu-terised database on which all A&E data, including timeand date of presentation, investigations, diagnosis, anddeparture destination (from A&E), are logged by theA&E medical team. This database was then used to iden-tify those patients from this hip fracture cohort whorepresented to this same A&E department within 1-yearof the fracture. Data on the presenting complaint, provi-sional diagnosis, and outcome (admission/dischargehome/referral to other services) was obtained at thistime.

Results1108 patients who suffered a fractured neck of femurbetween 1 January 2002 and 31 December 2007 wereidentified from the A&E database. 234 of these patientsrepresented to A&E on a total of 368 occasions within 1-year of their original presentation with a hip fracture;77% (284/368) of the representations necessitated acuteadmission (Figure 1). Falls, including a collapse of

uncertain aetiology, accounted for 20% (57/284) ofadmissions; 59 patients (20.7%) were admitted with afracture, of which 23 were to the contralateral hip. Headinjury necessitated acute admission on 7 occasions(7 patients; 2.5% of admissions). Medical illness was theleading cause of admission (56.6% (161/284)) of whichinfection was the chief precipitant (28% (45/161)). Cardi-ovascular pathology was implicated in 5.3% (15/284) ofadmissions with five patients (1.8%) presenting with amyocardial infarction or acute coronary syndrome; car-diac arrhythmia was the underlying cause for 2.8%(8/284) of admissions and symptomatic cardiac failurefor 0.70% (2/284). Cerebrovascular events (stroke andTIA) accounted for 5.6% (16/284) of admissions. Otherless common causes of medical readmission includedacute confusion (2.2.8%; 8/284), social incapacity (1.4%;4/284), and deliberate self-harm (1.8%; 5/284) (Table 1).50% of those patients who represented within 1 yearattended A&E within 4.5 months of the original injury.

DiscussionThe orthopaedic surgeon possesses a tried and trustedarmamentarium of options for the fixation of hip frac-tures. Irrespective of the technique employed the goal ofsurgery is the same–it is undertaken in the hope that itwill afford the patient pain relief and the possibility, oropportunity, to return to pre-injury mobilisation levels.Despite the best efforts of the surgical and multidisciplin-ary teams a significant proportion–nearly 1/3 ofpatients–will suffer declining health and die within ayear. Studies suggest that men and women who sustain ahip fracture have a 8-fold and 5-fold increase respectivelyin the relative likelihood of death within the first 3months when compared with age- and sex-matched con-trols [6]. For those that do survive, 10% will be unable to

Figure 1 Outcome of patients representing within 1-year and causes of readmission.

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return to their previous residence [7] and many more willendure a loss of independence requiring formal or infor-mal care provided by social support services or familyand friends. Exactly what contributes to this progressivedemise is unclear.In decades past the quality of service provision may

have been implicated; the management of osteoporoticor fragility fractures, of which hip fractures are the mostphysically and medically challenging, has traditionallybeen sub-optimal [5]. However, the past decade borewitness to considerable changes in the approach topatients with hip fractures. On the basis of work under-taken by the British Orthopaedic and Geriatric Societies,and with the inception of the National Hip FractureDatabase in 2007, there now exists evidence-based gui-dance on the management of hip fractures with empha-sis placed upon the establishment of multidisciplinarycare plans and secondary prevention. Patients who suffera hip fracture should expect to receive care that is com-pliant with the six standards outlined in the be BlueBook on the care of patients with fragility fractures,

including access to acute orthogeriatric medical supportfrom the time of admission and multidisciplinary assess-ment and intervention to prevent future falls [5]The results of this review revealed that 21% of patients

returned to A&E in the year following their hip fracturewith 77% of these return visits necessitating acute admis-sion. A fall was directly implicated in readmission on 57occasions and may have been implicated in a further 66admissions - 59 patients were admitted with a fractureand 7 patients with a head injury. Exactly how theseinjures were sustained is not known, but it would not beimplausible to suggest that a fall may be linked to some ofthese readmissions. If this were indeed the case, if a fallwas the underlying mechanism, it would mean that justunder half of all patients who were re-admitted (43%; 57known falls, 57 fractures, 7 head injures) required acutecare because of a fall. A fall may not have been the offend-ing mechanism in all cases–some patients may have sus-tained pathological fractures or injures following a roadtraffic accidents–but given the age group and populationwho most commonly suffer hip fractures there must be ahigh index of suspicion.Studies suggest that one half of individuals over the age

of 65 will suffer a fall each year and in over 50% of casesthe falls will be recurrent [8]. The risk of falling increaseswith age and with admission into medical and long-termcare institutions [9]. Secondary prevention of falls hasemerged as a tenet of the multidisciplinary managementof hip fractures. With a multitude of factors implicated,including symptomatic cardiovascular pathology such ascarotid sinus hypersensitivity or dysrhythmias, along withage related visiospatial decline and muscular decondition-ing, a comprehensive assessment of the underlying cause(continuous ambulatory ECG monitoring, tilt-table testingetc) and implementation of appropriate management andeducational strategies are indicated. If the cause can beidentified, prevention of further falls and reduction in theassociated morbidity is a possibility. The primary admis-sion should therefore be considered an opportunity toidentify those at risk patients and implement health careinitiatives to minimise this risk and maximise health.While secondary prevention may target falls risk and

osteoporotic fragility fractures, these prophylactic or pro-tective measures cannot address all facets of illness andmorbidity. Medical ailments were the leading cause ofreadmission (57%; 161/284) in this study with an infectiveprecipitant identified in 28% (45/161) of cases. Little canbe done to prevent individuals from developing pneumo-nia or a urinary tract infection, yet it is such illnesses,more than any other cause or complaint, that broughtthis hip fracture cohort back to A&E. Similarly, cardio-vascular and cerbrovascular pathology accounted for 11%of re-admissions. The orthogeriatric team may be able tooptimise patients medically in preparation for surgery

Table 1 Causes of readmission

Cause Number

Fall/collapse? cause 57

Fracture 59

Contralateral hip 23

Wrist 5

Pubic rami 3

Humerus 2

Vertebra 2

Femus 2

Other 22

Head Injury 7

Medical/surgicalillness

161

Cardiovascular

Myocardial infarction/ACS 5

Cardiac failure 2

Arrhythmia 8

Infection

Chest 19

Urinary tract 9

Skin 5

Wound 1

Septicaemia/sepsis? cause 11

Neurological/Psychiatric

CVA/TIA 16

Confusion 7

Deliberate self-harm 5

Other 73

Gynaelogical disorders, socialincapacity...

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but this is by no means permanent. The progressivedecline in health demonstrated by 30% of patients islikely an irreversible process that has been accelerated bythe hip fracture. As Goldacre et al. point out, the mortal-ity may be attributed to continuing fracture sequleae butmay also be due to the fact that individuals who fracturetheir hips are more frail and ill than the general popula-tion of the same age [10]. In such patients the hip frac-ture could be a ‘tipping point’, an insult for which thebody doesn’t have the reserves to overcome.The morbidity associated with hip fractures is variable

and multifactorial. The results of this retrospectivereview reveal that in a cohort of patients returning toA&E within 1-year of the original fracture, one-fifthwere admitted because of an event that may have beenanticipated and the risk reduced with measures (i.e.referral for falls assessment) instituted at the time of ori-ginal admission. This study did not look at whether anypatients were referred for falls assessment but it demon-strates the importance of complying with those stan-dards outlined in the Blue Book on the care of patientswith fragility fractures. It illustrates the need to lookupon the original admission as a opportunity to identifyat risk patients and institute measures to optimise healthand prevent re-injury and readmission; we should lookupon patients with a hip fracture as a ‘captive cohort’, aproportion of an aging population on whom we canapply targeted measures–medical, educational andsocial–in an attempt to improve or maximise health andminimise the progressive decline that affects nearly 1/3of all hip fracture patients.We readily accept that this review has a number of lim-

itations. Firstly, it does not take into account the morbid-ity and mortality of the 69% of hip fracture patients whodid not present to the Leicester Royal Infirmary A&E.Many patients will be managed in the community andpossibly even admitted to community hospitals ratherthan acute medical services. Similarly, we did not takeinto account those who may have left the catchment areaand therefore may have presented to other A&E depart-ments. Secondly, this review did not examine the localefrom which patients were presenting. Nursing home resi-dents or those in residential homes who receive regularskilled care and assistance may have lower rates of atten-dance compared with those who return to their ownhome or are reliant upon social service provision orinformal care by friends or family. Evidence of such dis-crepancy may account for the 1.4% of admissions due tosocial capacity. Lastly, this review utilised an emergencydepartment database to identify patients who suffered afractured neck of femur and the proportion of this cohortwho represented over the following year. Because of var-iations in coding this database has not yielded details on

every neck of femur fracture and the 1108 patientsincluded in this study are therefore a representative sam-ple of hip fracture patients seen in our institution. Simi-larly, this database cannot provide exact details about themechanism of injury and for those patients who returnedwith a fracture we do not know if this was a fragility frac-ture sustained following a fall from standing height orthe result of poly-trauma.

ConclusionThe morbidity and mortality associated with hip frac-tures is well documented. This review sought to exam-ine the prevalence and causes for representation andreadmission to acute medical services in the year follow-ing a hip fracture in an attempt to identify the leadingcauses behind this morbidity. The results of this reviewrevealed that the causes of representation and readmis-sion are variable and frequently multifactorial. Falls,fracture and infection were the leading causes of read-mission. One-fifth of readmissions, possibly more, mayhave a modifiable aetiology. This illustrates the impor-tance of identifying at risk patients during their originalpresentation and instituting guidance–namely referralfor falls assessment–outlined by the British Orthopaedicand Geriatric societies. Further work is indicated toexamine if those patients who actually undergo fallsassessment have a lower prevalence of falls and asso-ciated morbidity than those who do not.

Author InformationMr David J Bryson MRCS Core surgical traineeDr Scott Knapp MB BS Core medical traineeMr Rory G Middleton MRCS Specialist Registrar

Trauma and OrthopaedicsMr Murtuza Faizi MRCS Specialist Registrar Trauma

and OrthopaedicsMr Hardik Bhansali MRCS Specialist Registrar

Trauma and OrthopaedicsMr Chika E Uzoigwe MRCS Specialist Registrar

Trauma and Orthopaedics

Author details1Department of Trauma and Orthopaedics, Leicester Royal Infirmary,Infirmary Road, Leicester LE1 5WW, UK. 2Department of Trauma andOrthopaedics, Kettering General Hospital, Rothwell Road, Kettering,Northamptonshire NN16 8UZ, UK.

Authors’ contributionsStudy Design: CU, RM, MR, DB, SK, HBData collection: CU, SKData Analysis: DB, CU, RM, HB, SK, MF, DBWriting of the paper: DB, CU, RM, HB, SK, MFAll authors read and approved the final manuscript

Competing interestsThe authors declare that they have no competing interests.

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Received: 20 June 2011 Accepted: 21 December 2011Published: 21 December 2011

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doi:10.1186/1749-799X-6-63Cite this article as: Bryson et al.: Representation to the accident andemergency department within 1-year of a fractured neck of femur.Journal of Orthopaedic Surgery and Research 2011 6:63.

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